Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Countryside Health Care Of Milford during CMS and state inspections, most recent first.
Hand hygiene was not performed as required during medication administration for two residents on EBP, including before entering rooms and between glove changes for one resident receiving eye drops and insulin. In addition, an oxygen concentrator filter for a resident with COPD and continuous O2 was observed repeatedly covered with thick gray debris, despite manufacturer guidance and facility policy calling for weekly filter cleaning.
A resident’s discharge MDS was not completed in a timely manner after discharge. The MDS Coordinator said the assessment was missed despite a monthly report used to track timely completion and transmission, and the CMS RAI Manual requires assessments to be completed and transmitted within specified timeframes.
The facility failed to properly store and label medications in three out of four medication carts. Unlabeled and uncovered medication cups with loose pills and crushed Pepcid were found in the Memory Care Unit. Additionally, opened eye drop bottles on the [NAME] and Pichetti Units were not labeled with an open date. The DON confirmed the importance of proper labeling and storage practices.
The facility failed to report two incidents to the Department of Public Health's HCFRS as required. A resident with severe cognitive impairment had a bruise of unknown origin that was not reported within 24 hours. Another resident with dementia reported an alleged abuse incident that was not reported within the required two-hour timeframe. The facility's staff did not report these incidents, citing unsubstantiated investigations and the resident's history of delusions.
A facility failed to develop a care plan for a resident with an indwelling urinary catheter, despite the resident being cognitively intact and having a catheter due to neuromuscular dysfunction of the bladder. Staff interviews revealed that the omission was an oversight, with daily catheter care being provided but not documented in the care plan.
A resident with chronic kidney disease and type II diabetes was self-administering medications without a physician's order, contrary to facility policy and professional standards. The resident was observed taking medications privately, and staff interviews revealed that the required physician's order and care plan were not in place. The facility's protocol for self-administration was not followed, as the nurse did not consistently verify medication intake.
A facility failed to provide appropriate dialysis care for a resident by not obtaining physician orders for the removal of a pressure dressing on the AV fistula, failing to monitor the site for complications, and lacking a comprehensive care plan for the AV site. Staff interviews revealed a lack of awareness regarding the dressing protocol, and the resident required assistance to remove the dressing, highlighting gaps in procedures and communication.
The facility failed to transmit MDS assessments within the required timeframe for two residents. According to CMS guidelines, assessments must be completed within 14 days after the ARD and transmitted within 7 days of completion. However, assessments for a resident with ARDs in June and July were not transmitted until November. The MDS Coordinator confirmed the delay in transmission.
A facility failed to accurately code the diagnosis of depression on six out of seven MDS assessments for a resident admitted with depression. The facility's policy requires accurate assessment using the RAI, but this was not followed. Interviews with the MDS Nurse and DON confirmed the oversight and the need for modifications.
Hand Hygiene and Oxygen Concentrator Sanitation Failures
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to help prevent the development and potential transmission of communicable diseases and infections. During medication administration, Nurse #1 did not perform hand hygiene before entering the rooms of two residents who had CDC Enhanced Barrier Precautions (EBP) signs posted on their doorframes. For one resident, the nurse also removed one pair of gloves after giving eye drops and then put on a second pair of gloves to administer insulin without performing hand hygiene between glove changes. The nurse stated both residents required EBP because of indwelling urinary catheters, and the DON and Infection Control Nurse stated hand hygiene should be performed prior to entering a room requiring EBP and after glove removal. Resident #83, who was admitted with COPD and had diagnoses including asthma, COPD, or chronic lung disease, was receiving continuous oxygen therapy. The resident’s physician orders included continuous oxygen and weekly changes of oxygen/nebulizer/humidification setups, but there was no order addressing cleaning or changing the oxygen concentrator cabinet filters. On multiple survey observations, the resident’s Invacare Platinum XL Homefill II Compatible with SensO2 oxygen concentrator had a cabinet filter covered with dry, thick gray debris. The manufacturer’s guidelines for the oxygen concentrator indicated the cabinet filter should be removed and cleaned at least weekly, and the facility’s respiratory supplies policy stated reusable filters should be rinsed in warm water weekly. During interviews, nursing staff and the DON acknowledged the filter should have been cleaned and should not have visible debris. The observations and interviews showed the oxygen concentrator filter was not maintained in a sanitary manner.
Delayed Discharge MDS Assessment
Penalty
Summary
The facility failed to complete a discharge assessment to ensure timely coding and transmission of a Minimum Data Set (MDS) assessment for Resident #48. The resident was discharged from the facility on 10/30/25, but a discharge MDS was not initiated until 1/28/26, 59 days after discharge. During an interview on 1/28/26 at 11:02 A.M., the MDS Coordinator stated the discharge assessment was not completed and explained that she runs a monthly report to ensure assessments are completed and transmitted timely, but this assessment must have been missed. Review of the CMS Resident Assessment Instrument (RAI) Manual, Version 3.0, indicated assessments must be completed no later than 14 calendar days after the ARD and transmitted and encoded within 7 days of assessment completion.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that all medications were stored and labeled according to accepted professional standards, as observed in three out of four medication carts reviewed. During an observation on the Memory Care Unit, a surveyor found three small clear plastic medication cups in the top drawer of the medication cart, all uncovered and not labeled. These cups contained loose pills and applesauce with a white powdery substance, identified as Pepcid. Nurse #3 admitted to placing loose pills found in the cart into the cups for disposal, without knowing what they were, and prepared the crushed medication for a resident who was unavailable to take it. Further observations on the [NAME] Unit and the Pichetti Unit revealed that bottles of eye drops, including Latanoprost and Dorzolamide, had broken seals indicating they had been opened but were not labeled with an open date. Nurse #4 stated that the night shift was responsible for maintaining the medication cart and ensuring proper labeling. The Director of Nursing confirmed that medications should not be stored in the cart once prepared for administration and emphasized the importance of labeling eye drops with the date opened due to their shortened expiration date.
Failure to Timely Report Abuse and Neglect Allegations
Penalty
Summary
The facility failed to timely report completed investigations to the Department of Public Health's Health Care Facility Reporting System (HCFRS) as required for two residents. For one resident, who was admitted with cerebrovascular disease and had severe cognitive impairment, a bruise of unknown origin was observed on the upper lip. The facility's policy required such incidents to be reported within 24 hours, but the Director of Nurses did not report it, believing it was unnecessary since the investigation did not substantiate the allegation. Another resident, admitted with dementia and other behavioral disturbances, reported an incident involving a man with silver hair who allegedly pounded his fists at the resident. Despite the resident's fear and report to the Administrator, the incident was not reported to the HCFRS within the required two-hour timeframe. The Administrator and the Director of Nurses did not report the incident, citing the resident's history of accusatory behaviors and delusions, and the investigation's inability to substantiate the claim.
Failure to Develop Care Plan for Indwelling Urinary Catheter
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan for a resident with an indwelling urinary catheter. The resident, who was admitted in June 2024 with metabolic encephalopathy and was receiving hospice care, was cognitively intact and had a catheter due to neuromuscular dysfunction of the bladder. Despite the facility's policy requiring care plans to be developed at admission and updated regularly, the resident's care plan did not include any information regarding the catheter. Interviews with facility staff revealed that the omission of the catheter care plan was an oversight. Nurse #2 confirmed that catheter care was provided daily but was not documented in the care plan. The Unit Manager acknowledged that the care plan should have been established months ago, and the Director of Nursing stated that care plans should reflect the resident's current medical status, indicating that the lack of a care plan for the catheter was a deficiency in meeting the resident's needs.
Failure to Obtain Physician's Order for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure professional standards of care were met for a resident who was self-administering medications without a physician's order. The Massachusetts Board of Registration in Nursing Advisory Ruling requires a licensed nurse to ensure there is a proper patient care order from a duly authorized prescriber before the administration of any medication. The facility's policy also mandates that a resident may self-administer drugs only if ordered by the attending physician and deemed safe by the interdisciplinary team. However, the facility did not obtain a physician's order for the resident to self-administer medications, which is a violation of both the advisory ruling and the facility's policy. The resident, who was admitted with chronic kidney disease and type II diabetes, was observed by a surveyor to be self-administering medications without supervision. Nurse #1 prepared the medications and left them at the resident's bedside, allowing the resident to take them privately. The resident confirmed that they had been self-administering medications for a few months and that the nurse did not always return to ensure all medications were taken. The Medication Administration Record indicated that the resident was receiving these medications daily, but there was no physician's order for self-administration in the resident's active orders. Interviews with the nursing staff, including Nurse #1, the Unit Manager, and the Director of Nursing, revealed that the facility's protocol for self-administration of medications was not followed. The Unit Manager and the Director of Nursing acknowledged that a physician's order and an updated care plan were required but were not in place for this resident. The Director of Nursing emphasized that the nurse should always return to ensure all medications are taken and document their findings, which was not consistently done in this case.
Failure to Implement Proper Dialysis Care and Monitoring
Penalty
Summary
The facility failed to provide appropriate dialysis care and services for a resident who required such services. Specifically, the facility did not notify the physician or obtain orders for the removal of the pressure dressing applied by the dialysis center to the resident's left arm AV fistula. Additionally, the facility did not monitor the AV site for complications or signs of infection, nor did they develop and implement a care plan for the care and maintenance of the AV site. The resident, who was admitted with diagnoses including dependence on renal dialysis and chronic kidney disease, was cognitively intact and receiving dialysis three times a week. The physician's orders for the resident included dietary restrictions, dialysis schedules, and assessments for the AV fistula, but failed to include orders to assess the site upon return from dialysis or instructions related to the pressure dressing. The comprehensive care plan also lacked interventions to monitor the site for adverse effects or complications. Interviews with staff revealed a lack of awareness and understanding regarding the care and maintenance of the resident's AV fistula. The Unit Manager and a nurse were unaware of the dressing protocol, and the Director of Nurses acknowledged the need for an order to remove the dressing. The resident expressed that staff assistance was needed to remove the dressing, indicating a gap in the facility's procedures and communication regarding dialysis care.
Failure to Transmit MDS Assessments Timely
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were transmitted within the required timeframe for two residents. According to the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual, assessments must be completed no later than 14 calendar days after the assessment reference date (ARD) and transmitted within 7 days of assessment completion. For Resident #40, a discharge MDS with an ARD of 6/13/24 and an entry MDS with an ARD of 6/14/24 were not transmitted until 11/13/24. Similarly, for Resident #101, a discharge MDS with an ARD of 7/9/24 was also not transmitted until 11/13/24. During an interview, the MDS Coordinator confirmed that the assessments were completed but not transmitted in a timely manner as required.
Failure to Accurately Code Depression Diagnosis in MDS Assessments
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) assessments for a resident diagnosed with depression. Specifically, the diagnosis of depression was not coded on six out of seven MDS assessments reviewed for the resident, who was admitted to the facility in October 2023 with a diagnosis that included depression. This oversight was identified during a review of the facility's policy on Resident Assessment Instrument and Care Planning, which mandates that each resident be assessed using the Resident Assessment Instrument (RAI) as specified by the state. Interviews with the MDS Nurse and the Director of Nurses confirmed that the diagnosis of depression should have been coded on each of the MDS assessments and acknowledged the need for modifications.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Milford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Blaire House Of Milford | 2.1 mi | ★★★★★ | 2 | 0 |
| Oc Milford Gardens Llc | 2.7 mi | ★★★★★ | 13 | 0 |
| Adviniacare At Northbridge | 5 mi | ★★★★★ | 6 | 0 |
| Blackstone Valley Health And Rehabilitation | 6.3 mi | ★★★★★ | 0 | 0 |
| Lydia Taft House | 7.2 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.